Beyond the Cuckoo’s Nest

One of the oldest mental hospitals in the US is the still-standing Friends Hospital in Philadelphia. Founded in 1813 by Quakers, the institution did not always have such a brief name. It was originally the Asylum for Persons Deprived of the Use of Their Reason, and it sought to house and treat the severely mentally ill. For much of the 1800s, institutions like this were a common sight in communities including Portland. They eventually gave way to much larger, warehouse-like institutions, which in turn were shut down in the mid-20th century. This is a primer on how we got to where we are today: a country that once locked away the severely mentally ill, to one that now sees them, daily, on the street.

The House of Hawthorne

Hawthorne Asylum, ca. 1872

In the US, the earliest attempts at grappling with mental health were not really about treatment. They were about sequestering the mentally ill away from society at large.

“People with mental health issues were put in courthouses or jails, and just left to vegetate there,” says David Pollack, a professor of public policy at Oregon Health and Science University’s Department of Psychiatry, and former Medical Director for the Office of Mental Health and Addiction Services in the Oregon Department of Human Services. According to Pollock, medical facilities in early America were not much better. Poor conditions in existing facilities led to a reform movement for safer, regulated government facilities.

One notable advocate in the early 1800s for better mental health treatment was Dorothy Dix.

“She was appalled by the conditions she saw,” says Pollock, “so she went with colleagues to 37 state legislatures and convinced them to build hospitals to care for people. These were the asylums…. Then she convinced Congress to pass a similar bill. That bill passed, but it was vetoed by Franklin Pierce prior to the Civil War, because he was concerned about pushback from advocates of state’s rights. Federal involvement in mental health policy was set back by a century.”

Despite the lack of federal involvement, though, state hospitals cropped up throughout the country. Oregon’s first go at housing the mentally ill was the Hawthorne Asylum near what is now Southeast 12th and Salmon.

“The Hawthorne Asylum was a private asylum run by Dr. Hawthorne. The state paid him to take care of mentally ill patients,” says Diane Goeres-Gardner, author of Inside Oregon State Hospital. “It was considered to be a very, very nice place. Dorothy Dix came to Oregon to visit it and thought very highly of it.”

Despite its relative progressiveness for its time, the reasons people were held in the asylum may seem strange to a modern Portlander.

“In 1863 there were five women and 29 men living in the asylum,” says Goeres-Gardner, “with diagnoses of melancholia, mania, monomania, and idiocy.”

According to Neal Wallace, a professor of public administration at Portland State University (PSU), many American mental health institutions were also where you put people who transgressed social norms.

“A lot of the times putting people into these psychiatric hospitals was stigmatic,” he says. “They put unmarried pregnant women into psychiatric hospitals—stuff like that.”

Regardless of the cause of detention, the Hawthorne Asylum was not a viable long-term solution for the state.

“By about 1877 it was costing the state about $70,000 a year to keep the patients there,” says Goeres-Gardner, “which was about 42 percent of the Oregon tax base.”

The Hawthorne Asylum was eventually supplanted by the Oregon State Hospital (OSH) in Salem.

“A lot of it was about money—but it was also about the fact Dr. Hawthorne passed away,” says Goeres-Gardner, who speaks of the early days of OSH in fairly glowing terms.

In its time, the OSH was considered one of the best in the country, and would typify the large state-run mental health institutions that would act as homes, treatment centers, holding areas, and communities for its residents. It theoretically solved the problems of housing while treating the severely mentally ill.

“It was a model [for the nation],” says Pollack.

The Age of Institutions

Main entrance of the Oregon State Hospital in Salem, 1940

For sure, the OSH was not a place where you’d go and see your therapist or pick up a prescription. It was an interior world unto itself.

“All the patients lived there. Even the staff lived there,” says Goeres-Gardner. “It was not the belief that [patients] could get out in the community,” says Pollack, “but at least they could be cared for in a safe and humane way.”

But it wasn’t like patients were under constant observation by doctors or researchers.

“If a patient saw a doctor once a year, they were lucky,” says Goeres-Gardner.

Like virtually every other American mental health facility before it, the goal of the hospital was containment, more so than treatment.

“The idea was not to cure them,” says Goeres-Gardner. “The idea of the asylum was to keep society safe, and to keep the ill persons safe.”

Unfortunately, medicine at the time generally did not have any better alternatives.

“In the late 1800s that was generally the best care,” says Wallace of institutions like the OSH. “People were put in these large, mostly rural hospitals where they were supposed to be out in the fresh air and work on farms…. Over a long time, they turned into the hellholes they became.”

According to Goeres-Gardner, the OSH started to decline in quality in the mid-20th century.

“From 1950 to 1965 or so, those were hard years,” she says. According to her, the hospital was understaffed and underfunded, and patients also functioned as staff.

“They did the cooking, the cleaning, the yardwork, all that sort of thing,” Goeres-Gardner says.

A major blow to the hospital, though, was a series of federal laws which said patients could not be required to work. That, notes Goeres-Gardner, hit the hospital’s bottom line, which in turn impacted the quality of life of the residents.

As time went on, the ideal of a serene, ordered institution offering fresh air and safety to its residents was almost never a reality.

“Hospitals and institutions were places where there were rampant injustices and brutal treatment,” says Greg Townley, an assistant professor of community psychology at PSU. “There was a notion of warehousing folks. In the 1950s, half a million people were neglected and left to rot in these warehouse environments.”

According to Townley, that bad state of affairs led to a nationwide campaign to dramatically change how it approached treating severe mental health problems.

“There was a notion that people should be able to receive services in their community,” he says. “Taking someone out of their community is not conducive to well-being and recovery. It’s segregating.”

The Campaign for Deinstitutionalization

As residential mental health institutions began to deteriorate in the 20th century, a campaign for a new model of treatment began. The first inklings of government action for deinstitutionalization came in the Eisenhower administration.

“There’s a report that got developed during the Eisenhower administration called Action for Mental Health,” says Pollack. “The report recommended a community-based treatment approach.”

Pollack notes the report did not lead to any immediate legislation, but it did bring the issue to light, and the Kennedy administration eventually picked up the cause of community-based mental health. According to Pollack and Wallace, shutting down institutions was not primarily motivated by concerns about costs. It wasn’t anti-tax conservatives leading the charge against state spending on mental health. At the beginnings of deinstitutionalization, opening up the old state hospitals was a progressive issue.

“[One issue] was civil liberties,” says Wallace. “Many people who were in institutions were getting terrible care or being abused, strapped down and put in confinement. It was really ugly…. There was a right to refuse treatment, and a right to be in the community and not be incarcerated.”

There were other more practical concerns as well. New drugs and new social programs made outpatient policies more possible in the mid-20th century. Social security and disability payments would provide income to people who would have formerly been entirely destitute. That, and some of the hardest cases got a new drug that would make it more practical for them to be in the outside world.

“Another factor was the development of Thorazine,” says Townley. “It’s an antipsychotic that helps to relieve symptoms of schizophrenia, which is one of the more debilitating mental illnesses.”

On top of that, Wallace bundles deinstitutionalization into an array of progressive programs being passed in the 1960s.

“Deinstitutionalization came up at the same time we were doing Medicare and Medicaid,” he says. “It [was] a progressive social welfare political issue.”

In 1963, in one of his last acts as president, John F. Kennedy signed the Community Mental Health Center Act.

“It authorized states to get federal money and support them in creating community-based mental health centers with geographic jurisdictions, and they would serve that community,” says Pollack, “whether it was rural or urban.”

“The hope was that [community mental health centers] would be integrated throughout the community,” says Townley. “There was this notion of a housing continuum where people would be released into a controlled environment and go all the way to independent housing.”

During this time of progressive reforms, the Oregon State Hospital in particular was singled out for bad behavior by Ken Kesey’s novel, One Flew Over the Cuckoo’s Nest. According to Goeres-Gardner, though, the association might be a little unfair.

“He wasn’t writing about the Oregon State Hospital,” says Goeres-Gardner, who says that most of Kesey’s experience was with a California military hospital in California as opposed to a real Oregon institution. “The reason it’s associated with the Oregon State Hospital is because that’s where they filmed it.”

”Over-dramatizing it to some degree didn’t lend itself to the right solution,” says Wallace of Cuckoo’s Nest. “It made it clear that it was bad—but it didn’t say what to do to make it right.”

Out of the Hospital, Onto the Street

Reality did not deliver on the hopes of the 1960s. Of the envisioned community mental health centers, Townley says, “They exist, but they exist at a level far below the need.” Part of that, says Pollack, was inevitable.

“There was this notion they could be all things to all people,” he says of Kennedy’s proposed mental health centers. “They were kind of over-promising what they could do.”

Pollack also notes that professionals who had been familiar with the old system were, at the time of transition, not well-suited to the new way of doing things.

“The leadership was not consistent,” he says. “These psychiatrists, they were not trained to do community mental health.”

Another problem, though, was more practical, and just came down to money.

“By 1977, 650 of the 2,000 facilities were in place,” says Townley.

The Carter administration moved to fix things with the Mental Health Systems Act (MHSA) of 1979, which was signed in 1980. But it wouldn’t last.

“Unfortunately the Reagan administration repealed Carter’s plan to beef up or bolster supports in the original act,” according to Townley.

The MHSA eventually met its end, killed by the boringly-titled Omnibus Budget Reconciliation Act of 1982.

“It ended any federal government role in providing supports for individuals with mental illness,” Townley notes. “The [Reagan] administration established block grants for states, and these were implemented with varying levels of success.”

“Varying levels of success” meant that sometimes people in need of services would get what they needed. When they couldn’t, they ended up on the streets or in prisons.

Townley emphasizes that deinstitutionalization did not cause increases in incarceration and homelessness.

“It’s only one factor,” he says. “You also have to consider things like poverty and housing availability.”

He also notes that the closure of single-room occupancy dwellings, residential hotels, and other low-income housing also greatly contribute to homelessness. The current state of homelessness in the US in general, and Portland in particular, was not caused by the Kennedy administration moving away from state hospitals. But failure to adequately care for people with severe mental illness was a factor. Townley’s estimate is that about a quarter of all people experiencing homelessness have some kind of severe mental health issue.

Wallace is less exact with the numbers, but emphasizes that untreated mental health issues are still a huge contributor to homelessness.

“There’s a wide variety of estimates, but it’s always large,” he says, regarding numbers about homelessness and mental health crossover. He also notes that even when people with severe mental health issues do have housing, it may not be adequate to their needs.

Pollack emphasizes that, in many ways, the criminal justice system now plays some of the role that was once the purview of old asylums and hospitals.

“People in various degrees of correctional facilities—local, state, federal—20 percent, at least, probably have some kind of psychiatric condition,” he says.

Pollack sees the high numbers of incarcerated persons suffering from severe mental health issues as a social dilemma.

“If we don’t take good care of these people in jail, then it’s inhumane,” he says. “But then, if we provide really good care in jail, we take society off the hook for making bad decisions, [such as] putting people in jail instead of a health facility.”

Pollack adds that, in prison, there’s a spectrum for how well mental health is managed.

“How they’re treated ranges from marginally good to scandalously bad,” he says.

The Hawthorne Asylum is gone. The Oregon State Hospital still exists, but in a very different incarnation than when Cuckoo’s Nest was filmed there. The so-called “warehouses” and holding cells are no more—but, in a way, were never adequately replaced. Regardless of the many problems the asylum system presented, our current method of abandoning the mentally ill on Portland streets isn’t a sustainable solution.